HomeMy WebLinkAbout020-1140-30-000
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• AS BUILT SANITARY SYSTEM REPORT
R ' fr. O- F 0/y 4 -,J~/ , TOWNSHIP e/'o _SEC. T N, R W
.o. ADDRESS ST. CROIX COUNTY, WISCONSIN. .
~DIVISI0.1_,y >F ~`z, i~1- LOT LOT SIZE .
PLAN VIEW
-Distances S dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
--a
r
-r-;--, --t--
14
Indicate North; Arrota j
I 'SCALE : G!
tPTIC TANK (S) ) MFGR. CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
ANCHES NO. of width length area
no. of lines width /S length _Z_ areaa,_`t'
depth to top of pipe
AGREGATE ✓ 2 s
?ARK RATE AREA REQUIRED AREA AS BUILT
1►Sciaimer: The inspection of this system by St. Croix County does not imply complete
.o;pliance with State Administrative Codes. There are other areas that it is not possible
,p inspect at this point of construction. St. Croix County assumes no liability for
ystem operation. However, if failure is noted the County will make every effort to
,etermi.ne cause of failure.
JEASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
INSPECTOR
DATED
PLUriBER ON JOB ;
LICENSE NUMBER 3~5~
RLPORT OF INSPECTION - INDIVIDUAL _ ELWAGE SVSTI M
Sang -t.any P cicrn.i -
S .t a t e S e p t ,4. cc_) =!-~o---
1ME Towvt6h4.p -St. Cn04x County
ca,tionl~e 41e,C) Sec.Uon Lot Subdivision
IPTIC TANK
Size gaflona Numbe.n oA eompan-tmen-ta -
s tancc 0-om: Wel 8udtin9 ~ 12% 6Xope -
Htighwaten
IMPING CHAMB[ R
t
ti<ze gaUona Pumr.S ManuAac.tun.en Model Numbers.
i UINt~ TANK _ t
S4 ze at Pon,5 Numbers o{ Compa~ctmen to
Pumpe,c AEahm Sya-tem
tavic_e 6n-om: GIeU Bu.E,d4ng 12o 5 T o p e
H.Lghwa,ten
SORPTION SITE
lied T~Leneh
~.tance morn: CUe LK Bu. i.Q.dEng_~ ,12 % 5~ ope.
fl.i.ghwazen
SORPTION SITE DIMENSIONS
Width oA t4eneh6.t
-
Length o{ each fine 6,t Depth o6 kock below t~Xe
Numbe~i Depth. o6 noe.h oven t.~Xe Z- cn
7o tak keng h o ftine/s bt Depth o ~ tk' e betow ghade
DI_a tanee between Zinea_ e -fit Scope oo PC,( 100 A-
l otaf absonp,t.ton anew -L ` (I t Type. o6 Coven: Pap e_n orr 5 01 aw-'~
I DIMENSIONS
Numbers o6 pits G.. veP around plc'ta yea nu
Outa-i.de d_i.a.mcten :pth be0w tntet At
Io-ta~ abAo pt~.on area {~t
Area ncqu~tced f 5
.r
T 1 T L E
'PROVED DATE ' C 19 8 l
~
it CTED DATE 19
ASON FOR REJECTION
i
t~-
i y State and County State Permit #
PLB 67
Permit Application County Permit
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: '/4 '/4, Section T= N, R_4__ E (or) W Lot# City
Subdivision Name, neare r d, lake or landmark Blk# Village
Township
C. UPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family r, Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
-
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 4, Total Absorb Area sq. ft.
New V Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length Width Depth Tile depth (top) --No. of Lines '
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land Distance from critical slope
WATER SUPPLY: Private W Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME C.S.T. # and other information
obtained from (owner/builder).
Plumber's Signature MP/MPRSW# Phone # } -
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
m -
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a , gat v u ~v,
Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application IL'_ ;-Q Q ,~y Fees Paid: State/?,4"- ) County ate U ~
Permit Issued/Rviretetd (date) Issuing Agent Name
Inspection Yes__No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78
EH 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: Section -//-,T N,RE (or) W, Township or Municipality
Lot No.Block No. !!Yf /fe-L/ -OFG MOW B~-d2 County 3f
DES 1~1~~/ C~L$ Subdivision ame
Owner's/Buyers Name:
L)6 #EILXV s Hudson L~ Is S ~i ~ P/1
Address: ,
TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL
49
X47
EFFLUENT DISPOSAL SYSTEM: NEW - REPLACEMENT ALTERNATE SYSTEM Q~FC91-Itrm
DATES OBSERVATIONS MADE: rS7OIL BORINGS Mae PERCOLATION TESTS MCA Z 2_
- 1
SOIL MAP SHEET 5Cs 3 NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-2- 7"0 62
P-
P J 3& ~DE.VI// ~~/L U ~`t~ 3Cn N _ Cj ^ < (D
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 12 lvartoc > 72- L "PA& -)3) 1,► *I, s /l cs
B- Z ? -P > 7 2- A, IS VS'?), s D'4. iyi~o: s a w4 - a' . fly S .31" Cs &)/r B- 3 -7Z N®NE' > 72 G' A1. fS 3'Y1 O. If a"f~E s. '4i,
Fo, s ,,Q~ C7 . c S
B- 72- NaP- 72- ",~v /S 3 '/S w car 8~ itp.S 25-' -O G$
B- 72Z- IVPA, _ ? -72- '/7VA /X110. S 2-2 "0.3y~E
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locatI d square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 6/'i f0~ ~tv Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
~RopoJ~~ ~D~ 1/FaPTIcitL /.3~j % fi~EEC ~i~E Pi9ivTED .Ccb
ScT N yeacjvz)
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a ~ ~sT Y~' ,
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2 5" giejy/Y/~ P3 • • •R5 Iy /}ulex
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C~Pat%~i~~ i9.CEh~ J1/ 'T,EST S%TF~
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1, the undersigend, here y certify that the soil tests reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
33- I-/i
Name (print ,0- Certification No. -0270
Address 3 UOS~N ~f1/s . 5 ~Q~~
Name of installer if known
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Copy A --Local Authority ST Sienatu
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